Patient Information:
JD, 42 years, Male, African-American.
S.
CC: “I’ve been experiencing pain in my lower back for the past month, and it sometimes radiates to my left leg.”
HPI: A 42-year-old male presents with a one-month history of lower back pain that occasionally radiates to his left leg. The patient did not mention any recent injury, trauma, or significant precipitating event. Pain is described as constant and sharp, with an intensity of 6/10. Pain worsens with bending and lifting and is alleviated by rest and over-the-counter analgesics.
Current Medications: Over the counter NSAIDs for pain relief.
Allergies : No known drug allergies. Denies latex and environmental allergies.
PMHx: No known previous episodes of lower back pain. No history of chronic pain or spinal disorders. No previous surgeries. No significant medical history.
Soc Hx:Non-smoker, moderate alcohol consumption, sedentary job.
Fam Hx: The patient reports a family history of hypertension in his mother and father, and type 2 diabetes in his maternal uncle. There is no reported family history of spinal disorders or significant musculoskeletal issues.
ROS:
Vitals: BP 120/80 mmHg, HR 75 bpm, RR 16 bpm, Temp 98.6°F, SpO2 99%.
General: Alert, well-oriented, in mild discomfort due to pain.
HEENT: Normocephalic, atraumatic. PERRLA, EOMI. No lymphadenopathy or tenderness.
Neck: Supple, full range of motion, no vertebral tenderness.
Back: Paraspinal muscle tenderness in the lower back region, no visible deformity or swelling.
Neurological: Normal gait, normal strength in all extremities, sensation intact.
O.
Physical Exam:
General: The patient is alert, well-oriented, and in mild discomfort due to pain. He is well-groomed and appears to be in good general health.
Head: Normocephalic and atraumatic, no visible masses, depressions, or lesions.
EENT: Pupils equal, round, and reactive to light and accommodation (PERRLA). Extraocular movements intact (EOMI). Conjunctiva and sclera are clear. Tympanic membranes are intact, and nares are patent. No cervical lymphadenopathy or tenderness.
